ARTHRITIS MEDICATIONS

Transcription

1 CONSUMER S GUIDE ARTHRITIS MEDICATIONS Endorsed by the Canadian Rheumatology Association

2 A WORD ABOUT MEDICATION SAFETY The need to effectively monitor new drugs once they have been approved and introduced into the market has been a key advocacy issue for The Arthritis Society for several years. This advocacy helps to ensure that unfavorable side effects are reported, documented, and addressed. For regular updates on medications available in Canada, visit All medications have potential side effects whether they are taken by themselves or in combination with other herbal, over-the-counter and prescription medications. It is therefore important for patients to discuss the benefits and potential side effects of all their medications with their doctor. Health Canada s Marketed Health Products Directorate (MHPD) has recently developed a new website, named MedEffect. MedEffect s goal is to provide centralized access to new safety information about health products in an easy to find, easy to remember location. It also aims to make it as simple and efficient as possible for health professionals and consumers to complete and submit adverse reaction reports. Finally, it helps to build awareness about the importance of submitting adverse reaction reports to identify and communicate potential risks associated with certain drugs or health products. To find out more, visit: or call toll-free LIMITATIONS OF THE GUIDE: This guide does not replace your doctor it is essential that you see your doctor for proper diagnosis and treatment if you suffer from joint pain and swelling for longer than six weeks. This guide focuses on the treatment of osteoarthritis and rheumatoid arthritis in adults only. Treatment of other types of arthritis (including juvenile arthritis) is not included. If you are taking medication for another long-term health problem (such as heart, liver, and kidney conditions, high blood pressure, ulcers, or asthma), you should discuss possible drug interactions with your doctor. Also, if you are allergic to a specific medication, inform your doctor. If you are pregnant, trying to become pregnant or breast-feeding, you must inform your doctor since certain medications can be passed on through the placenta or into the mother s milk. If you are of child-bearing age, talk to your doctor about the importance of effective contraception.

3 CONSUMER S GUIDE TO ARTHRITIS MEDICATIONS WELCOME This is a very exciting time in the treatment of arthritis. Several new medications have recently been developed to combat joint pain and inflammation and more are on the way! Many of these medications are safer and more effective than ever before, expanding the treatment options for people with arthritis. The way in which doctors treat arthritis is beginning to change. We now know that for the best long-term health, as well as prevention of bone and joint damage, inflammatory arthritis (rheumatoid) needs to be treated early and aggressively. You can think of arthritis like a fire in the joints. Imagine there was a fire in your kitchen, if you leave it burning it will eventually destroy the kitchen and likely spread to other rooms in the house. The same is true for rheumatoid arthritis, if you leave the fire of arthritis burning it will eventually damage the bones and cartilage. The idea is to get the fire put out as quickly as possible to prevent the joints from becoming damaged. Again, if your kitchen was on fire it might take two or three fire trucks with their hoses to put the fire out. The same is true for arthritis, it might take two or three different medications to put the fire out. With this new approach to arthritis we are helping more and more people to lead normal active lives for years to come. Although medications are only part of arthritis treatment, they are a very important part. This Consumer s Guide to Arthritis Medications is designed to help answer some of your questions about these medications. You should also discuss any questions you have with your doctor. The more you know about your disease and your medications, the better off you will be. Andy Thompson, MD FRCPC WE NOW KNOW THAT FOR THE BEST LONG-TERM HEALTH, AS WELL AS PREVENTION OF BONE AND JOINT DAMAGE, INFLAMMATORY ARTHRITIS (RHEUMATOID) NEEDS TO BE TREATED EARLY AND AGGRESSIVELY. 3

4 AN INTRODUCTION TO ARTHRITIS WHAT IS ARTHRITIS? The word arthritis literally means inflammation of the joint ( Arth meaning joint and itis meaning inflammation). Inflammation is a medical term meaning pain, stiffness, redness, and swelling. WHAT ARE THE TYPES OF ARTHRITIS? There are over 100 different types of arthritis. To keep things simple we will divide arthritis into two categories inflammatory and degenerative. WHAT IS DEGENERATIVE ARTHRITIS? Cartilage is the tough elastic material that covers and protects the ends of bones. In healthy joints, cartilage acts as a shock absorber when you put weight on the joint. The slippery surface of the cartilage also allows the joints to move smoothly. When a joint degenerates, the cartilage gradually becomes rough, begins to wear away, and the bone underneath thickens. With this degeneration, the joint, may in fact, become inflamed with pain, warmth, and swelling. Although we see signs of inflammation in degenerating joints they are not considered to be inflammatory because the cause of the inflammation is the degeneration itself. Degenerative arthritis tends to affect the joint at the base of the thumb, the end and or middle joints of the fingers, the hips, the knees, and the joints at the base of the big toe. Most people notice degenerative arthritis as they get into their 40 s or 50 s, however, in some people it can start earlier. A person with degenerative joint disease may notice some stiffness of the affected joint in the morning lasting about minutes. As the day progresses and they use the joint the pain and discomfort typically increases and improves with rest. 4

5 WHAT IS INFLAMMATORY ARTHRITIS? Each joint in the body is lined by a thin layer of tissue called synovium. The synovium isresponsible for making small amounts of fluid to keep the normal joint lubricated. In cases of inflammatory arthritis, for some reason the body s immune system becomes confused and begins to attack the synovium. Chemicals released by the body s immune system cause swelling, pain, and stiffness of the joints and can eventually damage or destroy the cartilage and bone. Inflammatory arthritis can affect any joint in the body. The more joints involved tend to be the small joints of the hands and feet. Inflammatory arthritis can begin in a number of different ways. The most way is a slow onset of joint pain and stiffness starting in one joint and spreading to involve more joints over a period of weeks to months. It can also start very dramatically (almost overnight) or can start slowly with pain in joints that seems to jump around from joint to joint. Inflammatory arthritis causes aching, pain, stiffness, warmth, and swelling in the joints which are affected. The most striking characteristic is feeling stiff in the joints after rest. This is particularly apparent in the morning when the stiffness may take hours before feeling looser. In some people, the inflammation in the joints may be accompanied by a loss of energy (fatigue). Other symptoms might include low grade fevers, weight loss, muscle pain, or numbness and tingling in the fingers. Most patients have symptoms that continue steadily while others have symptoms that seem to wax and wane with times of more severe joint pain and stiffness alternating with better times. The severity of symptoms varies greatly from person to person. Once it is established, inflammatory arthritis is a chronic condition which will likely affect you for the rest of your life. As such, you will also need some type of medication to control your disease. It is usually a balancing act between taking as much medication as needed to control the arthritis and as little medication as necessary to prevent side-effects. Your doctor will adjust your dose or change your medications based on the latest results from your symptoms, findings on physical examination, and your laboratory tests. 5

6 A COMPARISION OF INFLAMMATORY & DEGENERATIVE ARTHRITIS FEATURES Who gets it? What is the cause? How does it start? How many joints does it affect? What joints can be affected? INFLAMMATORY ARTHRITIS Usually starts in middle age (30-60) and tends to get worse over time. However, it can start at any age The body s immune system attacks the joints ( Autoimmune ) Fairly quickly adding joints over a period of weeks to months Usually affects lots of joints and tends to be symmetrical involving joints on both sides of the body (i.e. both hands, both elbows etc) Small joints of the hands and feet Wrists, elbows, shoulders, knees, hips Any joint can be affected DEGENERATIVE ARTHRITIS More as we age and tends to occur in joints which have been worn down by excessive use Degeneration of cartilage Usually slowly with joints getting worse over a period of months to years Usually affects a few joints and tends to be asymmetrical ( not matching ) swelling and pain in single joints that are not part of a pair (i.e. one knee, one finger etc) End joints of the fingers Pain and swelling in bigger joints such as the knees and hips What are the usual symptoms? Joint pain, swelling, tenderness, and redness of the joints Prolonged morning stiffness; and less range of movement Some people also experience fever, weight loss, fatigue, and/or anemia. With use, the affected joints may become stiff, painful and enlarged Morning stiffness? Give examples of diseases? Morning stiffness lasting more than 60 minutes Rheumatoid arthritis Psoriatic arthritis Ankylosing spondylitis Systemic lupus erythematosus Morning stiffness lasting more than 20 minutes Osteoarthritis What are the treatment options? Non Steroidal Anti Inflammatory Drugs (NSAIDS) Disease Modifying Anti Rheumatic Drugs (DMARDs) Steroids Biologics Steroid Injections Analgesics NSAIDs Injections: steroids & viscosupplementation (Hyaluronic acid) 6

7 LIVING WITH ARTHRITIS I HAVE BEEN DIAGNOSED WITH ARTHRITIS? If you have been diagnosed with arthritis, you re certainly not alone; there is hope. A famous Canadian rheumatologist, Dr. Duncan Gordon is noted for saying, Everyone with arthritis can be helped. The management of arthritis involves a team including doctors, surgeons, nurses, physiotherapists, occupational therapists, social workers, pharmacists, dieticians, and YOU! Yes, you are an active member of your health care team. TREATING YOUR ARTHRITIS The treatment options for your arthritis will likely include both non-medication therapies such as physiotherapy, occupational therapy, education, exercise, and relaxation techniques, and medications. Medications to treat arthritis can be divided into two general categories those which only control symptoms and those which control the symptoms and the disease. MEDICATIONS FOR SYMPTOM CONTROL ONLY These are medications used to control the pain, stiffness, and swelling of your joints with the goal of improving your function. They are used for both inflammatory and degenerative arthritis. Painkillers (analgesics) and anti-inflammatory medications (NSAIDs) fall into this category They usually take days to weeks to work Although they may make your feel better they do not affect the course of the arthritis nor will they prevent the damage to bones and joints that can occur with the disease. Five Tips for Living with Arthritis 1 Get Educated: know the type of arthritis you have and the treatments available. 2 Stay Involved: be an active participant in decisions about your care. 3 Know Your Resources: know where to get the support and resources you need. 4 Stay Healthy: exercise regularly, eat a balanced healthy diet, and maintain a healthy weight. 5 Know Your Medications: tell your health care provider about all of the prescription and non-prescription medications you are taking. 7

8 SYMPTOM CONTROL PAIN MANAGEMENT Pain from arthritis can be so intense and constant that it dominates your every waking moment (and can cause many sleepless nights). Due to the pain, you may be unable to continue with your routine daily activities and you may become less active in an attempt to keep your joints as comfortable as possible. Unfortunately, this inactivity can then have negative effects on your muscles and joints. This can then lead to a loss of strength, reduced flexibility, and more pain. Therefore, good pain control is essential in the treatment of arthritis. Persistently severe pain from arthritis requires a combination of therapies as no single management technique is powerful enough to provide non-stop pain relief. You need to discover what works for you. This often means trying many different therapies or combinations of therapies for prolonged pain relief. NON-MEDICAL TECHNIQUES FOR PAIN CONTROL TECHNIQUES Physiotherapy Occupational Therapy Social Worker Psychology Massage Therapy Dietician The Arthritis Society Ice/heat application to joints Muscle strengthening General conditioning programs and aqua therapy Transcutaneous Electronic Nerve Stimulation (TENS) Joint protection measures Energy conservation techniques Braces and splints to support painful joints Adapting your home, vehicle, or workplace for your arthritis Special equipment (raised toilet seats, jar openers, reachers etc) Personal and family support Anger control techniques Community resources for financial techniques Relaxation techniques Therapeutic massage Diet advice for weight loss Arthritis Self Management Programs (800#, website etc) 8

9 NON PRESCRIPTION MEDICATIONS FOR PAIN Some pain-controlling medications can be bought over-the-counter without a doctor s prescription. You are probably familiar with many of these such as acetaminophen (Tylenol), ASA (Aspirin, Entrophen, Anacin, Novasen, etc), and ibuprofen (Motrin or Advil ). There are also a number of topical non-prescription creams and rubs to help the pain of arthritis. ACETAMINOPHEN Acetaminophen is a very safe and effective medication for pain relief which can be used for both short and long-term pain control. If you have pain from a degenerative arthritis (osteoarthritis) that is present most of the time, your doctor may recommend that you take acetaminophen regularly every four to six hours. When the pain is there all of the time, there is no point in waiting for it to become unbearable before taking your medication. Then you have to wait for the effects of the acetaminophen to catch up to the pain. Although acetaminophen is safe, it does have its limits: you can take two regular strength tablets (325 mg each) to a maximum of 12 tablets in one 24-hour period, or two extra-strength tablets (500 mg each) every six hours up to a maximum of eight tablets in a 24-hour period, or two extended-release tablets (Tylenol-Arthritis, 650 mg each) every eight hours up to a maximum of six tablets in a 24-hour period. Acetaminophen is found in other over-the-counter preparations such as cough and cold formulations. You must be careful to look at the ingredients of all of the over-the-counter medications you are taking to ensure you are not taking too much acetaminophen. The maximum daily recommended dose is 4 grams (4000 mg). IBUPROFEN & ASA Acetylsalicylic acid (ASA) and ibuprofen (Advil & Motrin) are non-steroidal anti-inflammatory drugs which can be purchased over-the-counter. You can learn more about NSAIDs in the chart on page 12. You must be careful to avoid taking ibuprofen with other NSAIDs your doctor may prescribe as it increases your risk of developing a stomach ulcer TOPICAL MEDICATIONS There are a number of over-the-counter creams and rubs available to help with the symptoms of arthritis. Some of these products contain salicylate (ASA) as the active ingredient whereas others contain capsaicin or menthol. Salicylate is available in Aspercreme, BenGay, and Flexall. Salicylates work by decreasing pain and inflammation. Capsaicin is found naturally in hot peppers, and sold under the brand names of Capzasin-P, Zostrix and other drugs. Capsaicin works by blocking the transmission of a pain-relaying substance called substance P to the brain. Camphor, eucalyptus oil and menthol are found in a variety of agents such as ArthriCare, Eucalyptamint and Icy Hot amongst others. These substances are able to relieve pain by tricking the body to feel the coolness or heat of these agents. NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS & COXIBS) 9

10 PRESCRIPTION MEDICATIONS FOR PAIN Sometimes over-the-counter painkillers are not strong enough for your pain. Your doctor can help by prescribing stronger pain medications such as NSAIDs (see table next page) or narcotics. Narcotics are a class of pain medication which includes items such as codeine and morphine (see table below). These medications should be taken under the direct supervision of your physician to monitor side effects. Common side-effects of narcotics include nausea, constipation, drowsiness, and a dry mouth. Because these medications slow down digestion (constipation), be sure to drink six to eight tall glasses of water throughout the day. COMMONLY PRESCRIBED NARCOTICS BRAND NAMES Tylenol #1, #2, #3, Codeine Contin Morphine, M-Eslon, MS-Contin Dilaudid, Hydromorph-Contin Percocet, Percodan, Oxycontin Demerol Duragesic patches PRODUCT Codeine Morphine Hydromorphone Oxycodone Meperidine Fentanyl Will I become an addict? Clinical research shows that people who take a narcotic at an appropriate dose for their level of pain are at low risk of becoming addicted. Why? Drug dependency is fuelled by psychological cravings for the euphoric effects of certain narcotics. Although codeine is a narcotic, when it s used for pain relief it usually doesn t produce the high that drug users seek. Still need convincing? Then ask yourself these questions: If you re not in pain and you don t take codeine, do you still feel a need for it? Do you require rapidly increasing doses to control the same level of pain? Finally, do you get high when you take codeine? Chances are you answered no to all these questions. If so, relax. You re not addicted to codeine. concerns 10

11 NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS & COXIBS) WHAT ARE NSAIDS? Non-steroidal anti-inflammatory drugs (NSAIDs) are a class of medications used to treat the pain and inflammation of arthritis. They do not contain steroids, hence the name non-steroidal. NSAIDs are a very large category of medications, some of which you can obtain without a prescription, such as ASA (Aspirin, Entrophen, Novasen) and ibuprofen (Advil or Motrin). The list of NSAIDs is long with over 20 currently available today. COXIBs are NSAIDs that have been custom-designed to minimize the risk of stomach problems. COMMONLY PRESCRIBED NSAIDS BRAND NAMES PRODUCT CLASS COMMON DOSE Voltaren, Voltaren-SR Arthrotec-50, Arthrotec-75 Ultradol Indocid Clinoril Toradol Diclofenac Diclofenac with Misoprostol Etodolac Indomethacin Sulindac Ketorolac Acetic Acids mg, 2-3 times daily mg, 2-3 times daily mg, 2-3 times daily mg, 2-3 times daily mg, twice daily 10 mg, 4-6 times daily Celebrex Prexige Celecoxib Lumiracoxib COXIBs mg, once or twice daily 100 mg once daily Relafen Nabumetone Naphthylalkanones 1000 mg, twice daily Mobicox Mobiflex Feldene Nalfon Ansaid, Froben, Froben-SR Meloxicam Tenoxicam Piroxicam Fenoprofen Flurbiprofen Oxicams mg, once a day mg, once a day 20 mg, once a day 600 mg, 3-4 times daily 100 mg twice daily Motrin, Advil Orudis, Oruvail, Rhodis Naprosyn, Naprosyn-SR Daypro Surgam, Surgam-SR Ibuprofen Ketoprofen Naproxen Oxaprozin Tiaprofenic Acid Propionic Acids mg, 3-4 times daily 50 mg, 3-4 times daily mg, twice daily 1200 mg, once a day 200 mg, 3 times daily Aspirin Dolobid Disalcid, Amigesic, Salflex Acetylsalicylic Acid (ASA) Diflunisal Salsalate Salicylates mg, 4-6 times daily mg, 2-3 times daily 1000 mg, 3 times daily 11

12 WHAT TYPES OF ARTHRITIS ARE NSAIDS USED FOR? NSAIDs are used for both inflammatory and degenerative types of arthritis. It is important to remember that these medications work to improve symptoms and have no proven long term benefits. As such, these medications can be taken on an as needed basis and do not need to be taken regularly. That being said, some patients may find it helpful to take their NSAID on a regular basis to control their symptoms. HOW LONG DO NSAIDS TAKE TO WORK? Some patients will notice the effects of an NSAID within the first few hours after taking a dose. In other patients the effects may not be evident for a few days and even up to a week or two after the medicine has been started. As a general rule, if it hasn t helped within 2-3 weeks it is unlikely to be of much benefit. WHAT IS THE TYPICAL DOSE OF NSAIDS? Every NSAID is different. Some are taken only once a day while others are taken up to four times a day. Your doctor will advise you of the correct dose to take. WHICH NSAID IS RIGHT FOR ME? There is no specific NSAID which will be right for you. Your doctor might ask you to try a few different NSAIDs as some may work better for you than others; these options and changes vary from person to person. People who should probably avoid NSAIDs & COXIBs Anyone who is allergic to NSAIDs or is allergic to Aspirin Anyone who has asthma which is made worse while taking Aspirin Anyone who has had a recent ulcer in the stomach or small intestine Anyone with liver or kidney disease should discuss this with their doctor Anyone with congestive heart failure Anyone who has had a recent heart attack, stroke, or experienced serious chest pain related to heart disease People who should be very careful taking NSAIDs & COXIBs Older patients (over age 65) Anyone who has had a previous stomach ulcer Anyone taking blood thinners such as Warfarin (Coumadin) or Heparin Anyone who has significant risk factors for heart attack or stroke should be aware that NSAIDs and COXIBs may increase this risk NSAIDs 12

13 IS THERE ANYBODY WHO SHOULD AVOID OR BE CAREFUL TAKING NSAIDS & COXIBS? Even though you can purchase NSAIDs like Aspirin, Motrin, and Advil without a prescription, some people should avoid taking them. WHAT ARE THE SIDE-EFFECTS OF NSAIDS & COXIBS? Indigestion, heartburn, stomach cramps and nausea are the most side effects of NSAIDs. NSAIDs can affect the protective lining of the stomach making you more susceptible to ulcers and bleeding. Ulcers usually cause stomach pain, nausea, and sometimes vomiting but in some people ulcers produce no symptoms whatsoever. Signs of stomach bleeding may include vomit that looks like it has coffee grounds in it, vomiting blood, or black, tarry bowel movements. See a doctor immediately if you develop any of these symptoms. NSAIDs can ly irritate the liver or affect the kidneys. These problems usually don t cause any symptoms. Fortunately they are and would be monitored by periodic blood tests if you are taking NSAIDs on a regular basis SIDE EFFECTS OF NSAIDS & COXIBS SYMPTOM FREQUENCY CALL DOCTOR Nausea / heartburn / stomach pain / cramps Constipation Vomiting or diarrhea Skin rash Ringing in the ears Dizziness or lightheadedness Increase in blood pressure Black or bloody stool Wheezing or shortness of breath Fluid retention Chest pain or pressure or persistent or persistent of persistent Yes Yes Yes Monitored periodically by your doctor Yes Yes Yes Yes DO I NEED ANY MONITORING WHILE I AM TAKING NSAIDS? You don t normally need regular bloodwork while taking NSAIDs. However, if you take NSAIDs regularly, your doctor will likely monitor your blood pressure and order periodic blood tests to ensure the NSAIDs are causing no problems with stomach bleeding or with your kidneys. 13

14 HOW CAN I HELP TO MINIMIZE SIDE EFFECTS OF NSAIDS? Taking your NSAIDs with food may help to reduce stomach upset. Taking a medication to protect the stomach or using a COXIB may be helpful in reducing the risk of serious gastrointestinal side effects. WHAT ARE THE RISKS OF HEART ATTACK & STROKE WITH NSAIDS & COXIBS Health Canada and the U.S. Food and Drug Administration (FDA) have reviewed all of the available studies on NSAIDs and COXIBs. Both groups have found that NSAIDs and COXIBs are both associated with an increased risk of cardiovascular events (angina, heart attacks, and strokes). The risk is greatest in those patients who use these medications for long periods of time and have risk factors for, or a history of, cardiovascular disease. Health Canada s recommendations are as follows: Do not use NSAIDs or COXIBs directly before, during or after heart surgery (bypass surgery) Patients with a history of cardiovascular disease (angina, heart attack, TIA, stroke, or congestive heart failure) should be careful using NSAIDs or COXIBs. Patients with risk factors for cardiovascular disease (diabetes, smoking, elevated cholesterol, obesity and family history) should also be careful using NSAIDs and COXIBs. Safer alternative treatments should be used if available. NSAIDs and COXIBs should be used in the lowest effective dose for the shortest possible duration of time. PLEASE DISCUSS THIS ISSUE WITH YOUR DOCTOR. WHAT ARE COXIBS? COXIBs are a new class of NSAIDs which have been developed to reduce the risk of gastrointestinal ulcers and bleeding. The two available COXIBs in Canada are celecoxib (Celebrex) and lumiracoxib (Prexige); however, others are under development. Although COXIBs are safer on the stomach they have all of the other side effects of NSAIDs and may still cause indigestion, nausea, stomach cramps, and heartburn. WHAT TOPICAL NSAIDS ARE AVAILABLE? In Canada, diclofenac (1.5%) is available in a topical preparation sold under the brand-name of Pennsaid. When applied as directed to the skin over a joint, very little of this medication is absorbed into the body which significantly reduces the usual side effects associated with NSAIDs. The side-effects of Pennsaid include dry skin and rash at the site of application. 14

15 PROTECTING YOUR STOMACH WHY IS PROTECTING THE STOMACH IMPORTANT? Some of the medications used to treat arthritis (NSAIDs, prednisone) can irritate the lining of the stomach. If this irritation persists or is particularly aggressive it may result in the formation of ulcers in the stomach or the first part of the small intestine (duodenum). Ulcers ly cause pain although sometimes they can be painless. WHO SHOULD RECEIVE MEDICATION TO PROTECT THE STOMACH? Patients that have stomach upset with NSAIDs or have risk factors for stomach ulcers (e.g. aged 65+, a previous stomach ulcer or bleeding from the bowels, using multiple NSAIDs including ASA, taking anticoagulants (coumadin), or corticosteroids) should discuss stomach protection with their doctor. WHAT MEDICATIONS ARE USED TO PROTECT THE STOMACH? There are currently two available stomach protection medications misoprostol and proton pump inhibitors. MISOPROSTOL Brand Name: Cytotec Supplied: 100 & 200 mcg tablets What is Misoprostol? Misoprostol replaces a naturally occurring substance that helps maintain the stomach s protective mucous lining. What is the typical dose and when do I take it? The usual dose of misoprostol is 200 mcg taken two to three times per day. The medication, Arthrotec, is actually a combination of an anti-inflammatory (diclofenac) and misoprostol. Is there anybody who should not take misoprostol? Any woman who is pregnant or may become pregnant should not take misoprostol since it can cause emergency complications such as an incomplete miscarriage. What are the side effects of Misoprostol? Your body may take two or three days to adjust to misoprostol, during which time, you may experience nausea, cramps, and diarrhea (loose stools). These side effects often disappear completely, but if they persist, contact your doctor. 15

16 PROTON PUMP INHIBITORS Brand Names: Esomeprazole (Nexium), Lansoprazole (Prevacid), Omeprazole (Losec), Pantoprazole (Pantoloc) Rabeprazole (Pariet) Supplied: Esomeprazole 20 & 40 mg tablets, Lansoprazole 15 & 30 mg tablets, Omeprazole 20 mg tablets, Pantoprazole 40 mg tablets, Rabeprazole 10 & 20 mg tablets What are Proton Pump Inhibitors (PPIs)? Proton pump inhibitors (PPIs) are a class of medications which work by stopping your stomach from producing ulcer-causing acid. When taken with an NSAID, PPIs reduce the risk of developing ulcers and promote ulcer healing. They are also quite good at reducing symptoms of stomach upset, such as nausea, heartburn, and indigestion. What is the typical dose and when do I take it? The dose varies depending on which PPI your doctor has prescribed. They are typically taken once to twice a day. What are the side effects of PPIs? Proton pump inhibitors have very few side effects. MEDICATIONS FOR SYMPTOM AND DISEASE CONTROL These medications are only available for the treatment of inflammatory arthritis because there are no known medications to slow down degenerative arthritis. They work to prevent joint damage and bone erosion in inflammatory arthritis that can lead to deformities. The goal is to keep your joints healthy for years to come. DMARDs and biologics fall into this category These medications often take 6-12 weeks to begin to have an effect. They work to address the root of the problem in inflammatory arthritis. Shutting down the inflammatory processes can take a long time but the result of healthy joints will be worth it. 16

17 DISEASE MODIFYING ANTI-RHEUMATIC DRUGS (DMARDs) WHAT ARE DMARDs? DMARDs are a class of medications used to treat inflammatory types of arthritis such as rheumatoid and psoriatic arthritis. Inflammation in the joint causes it to be warm, swollen, and sore. You can think of this inflammation like a fire in the joint. If we leave this fire going untreated it might burn down (damage) the joint. Once the joint is damaged it cannot be repaired. Rheumatologists know that putting out the fire is important to prevent damage to the joint. This is where DMARDs come in. DMARDs are medications which put out the fire (suppress inflammation) and help to prevent damage to the joint. Doctors know that prescribing a DMARD early on is important to prevent long-term damage. After all, if there was a fire in your kitchen you wouldn t wait until it spread to the living room you would try to put it out before it spread. This is the same idea with inflammatory arthritis! HOW LONG DO DMARDS TAKE TO WORK? DMARDs generally work well in most people; however, they do take some time to work. Most DMARDs will start to work in about 6 to 8 weeks; however, some may take longer up to 3 to 4 months. While you are waiting for the DMARD to work, your doctor might prescribe an additional medication such as prednisone or an NSAID to help control the symptoms. COMMONLY PRESCRIBED DMARDs BRAND NAMES Imuran Myochrisine Plaquenil Arava Methotrexate Salazopyrin PRODUCT Azathioprine Gold (Sodium aurothiomalate) Hydroxychloroquine Leflunomide Methotrexate Sulfasalazine COMMON DOSE mg daily 1 to 3 tablets daily 50 mg once weekly injection mg daily 1-2 tablets mg daily or every other day 1 tablet daily or every other day 7.5 to 25 mg once weekly 3 to 10 tablets once weekly OR 0.3 to 1.0 ml injection once weekly 1000 mg twice daily 2 or 3 tablets twice daily 17

18 WHICH DMARD IS RIGHT FOR ME? Although DMARDs can be used one at a time, many studies show that two or three DMARDs taken together is of greater benefit than one medication alone. Although there is no specific DMARD which will be right for you, your doctor will recommend a therapy that is best suited to your type or arthritis, other medical problems, and medications. Patients with mild arthritis may start with a single DMARD such as hydroxychloroquine or methotrexate. Patients with more severe arthritis, on the other hand, need more aggressive treatment and may receive two or three medications at the same time. HOW LONG WILL I HAVE TO TAKE MY DMARD? Once it is established, inflammatory arthritis is a chronic condition which will likely affect you for the rest of your life. As such, you will also need some type of medication to control your disease. It is usually a balancing act between taking as much medication as needed to control the arthritis and as little medication as necessary to prevent side-effects. Your doctor will adjust your dose or change your medications based on the latest results from your symptoms, findings on physical examination, and your laboratory tests. WHAT ABOUT SIDE EFFECTS? Unfortunately, everything in life carries some risk which must be balanced against the potential benefits. In general, the risk of joint damage and permanent disability is much greater than the risk of side effects to medications (DMARDs) used to control the disease. When properly monitored, the vast majority of side-effects are and most are reversible by adjusting the dose or switching medications. AZATHIOPRINE (AZA) Brand Name: Imuran Supplied: 50 mg tablets What types of arthritis is azathioprine used for? Azathioprine (AZA) is a DMARD used to treat inflammatory types of arthritis like rheumatoid and psoriatic arthritis. What is the typical dose and when do I take it? AZA is taken as tablets every day. The usual starting dose is 50 to 100 mg per day (1 to 2 tablets). Your doctor may further increase the dose to 100 to 200 mg per day (2 to 4 tablets). How long will it take to work? Unfortunately, like many of the DMARDs, you won t feel the effects of AZA right away. Most people start noticing the effects about 6 to 8 weeks after they start to take it. 18

19 Azathioprine Key Points 1 Take it once a day 2 Regular blood tests 3 Don t get pregnant 4 Call MD if you develop a rash 5 See MD if you develop a fever key points Is there anybody who should not take azathioprine? It is generally advisable to avoid all medications during pregnancy and breast feeding including AZA. However, under special circumstances, AZA has been used safely and successfully to treat arthritis during pregnancy. People with active infections, liver, kidney, or blood diseases may not be able to use AZA and should discuss with their doctor. Is there anything I should avoid when I am taking azathioprine? AZA has the potential to affect the liver (ly), and so your alcohol use must be limited. Talk to your doctor. Allopurinol, a medication used to treat gout, can have a severe interaction with AZA. Inform your doctor if you are taking allopurinol. What are the side effects of azathioprine? SYMPTOM Nausea & Diarrhea Skin Rash Liver problems Blood counts Infection Malignancy FREQUENCY very CALL DOCTOR Yes Monitored by regular blood tests Monitored by regular blood tests Yes Call if you think you have an infection When used for long periods of time AZA may be associated with an increased risk of skin or blood cancers; fortunately this is very. Do I need any monitoring while taking azathioprine? You will need regular blood tests to monitor your liver and blood counts for side effects of AZA. How to help reduce side effects? Take AZA as prescribed by your doctor. Reducing the dose may be helpful in reducing side effects. 19

20 GOLD Brand Name: Myochrisine Supplied: Vials of 10, 25, and 50 mg per ml What types of arthritis is gold used for? Gold is a DMARD used to treat inflammatory types of arthritis like rheumatoid and psoriatic arthritis. What is the typical dose and when do I take it? Gold is given as an injection usually once a week. A very small test dose (10 mg ) is given on the first week to make sure you are not overly sensitive. The second injection, a week later, builds up to 25 mg followed by 50 mg every week thereafter. If you respond very well to gold it may be possible to reduce the frequency of the injections to every two weeks or every month. How long will it take to work? Unfortunately, like many of the DMARDs, you won t feel the effects of gold right away. Most people start noticing the effects about 12 weeks after they start to take it. Is there anybody who should not take gold? Anyone who has had a prior allergic reaction to gold should avoid it. People with certain kidney or blood diseases may not be able to use gold and should discuss with their doctor. What are the side effects of Gold? SYMPTOM Skin rash and itchiness Mouth Sores Metallic Taste Aching in muscles and joints Allergic Reaction Blood counts Kidney Problems Lung Problems Bowel Problems FREQUENCY very very CALL DOCTOR Tell doctor before next injection is given as the gold may need to be temporarily stopped. Call if severe. Tell doctor before next injection is given as the gold may need to be temporarily stopped. Call if severe. No No Some patients experience weakness, faintness, dizziness, or nausea after receiving the gold injection. This usually goes away after you lie down for a few minutes. Monitored by monthly blood test Monitored by monthly urine tests Yes, call if you develop new shortness of breath Tell your doctor if you develop blood in the stool 20

21 Gold Key Points 1 Given ONCE A WEEK 2 Frequent blood and urine tests 3 Tell MD if you develop a rash, itchiness, or mouth sores key points Is there anything I should avoid when I am taking gold? Although it is generally advisable to avoid all medications during pregnancy, gold has been used safely and successfully to treat arthritis during pregnancy. Most medications can be given safely with gold. Do I need any monitoring while taking gold? At the beginning you will need blood and urine tests every week. After a few months the blood and urine can be tested every other week and then eventually monthly to monitor your blood counts and urine for side effects of gold. How to help reduce side effects? Inform your doctor of any rashes, itchiness or sores in the mouth prior to each injection of gold. Get your urine and blood tests done regularly as directed by your doctor. HYDROXYCHLOROQUINE (HCQ) Brand Name: Plaquenil Supplied: 200 mg tablets What types of arthritis is hydroxychloroquine used for? HCQ is a DMARD used to treat inflammatory types of arthritis like rheumatoid and psoriatic arthritis. What is the typical dose and when do I take it? HCQ is given as tablets taken once or twice a day and the dose is based on your body weight. Each tablet contains 200 mg of HCQ. The most dose is one to two tablets per day or 200 to 400 mg. If you require 300 mg per day your doctor may ask you to take two tablets one day and one the next. If you are taking two tablets a day you can take them both at once or take divide them up one in the morning and one in the evening. How long will it take to work? Unfortunately, like many of the DMARDs, you won t feel the effects of HCQ right away. Most people start noticing the effects about 6 to 8 weeks after they start to take it but the benefit may not occur for 3 months. 21

22 Is there anybody who should not take hydroxychloroquine? Anybody who has had a previous reaction to HCQ or has had eye problems as a result of hydroxychloroquine should avoid it. Anyone with problems with the retina of the eye should discuss with their rheumatologist. Is there anything I should avoid when I am taking hydroxychloroquine? No, in general most things are very safe when taking HCQ. Although it is generally advisable to avoid all medications during pregnancy, HCQ has been used safely and successfully to treat arthritis during pregnancy. What are the side effects of hydroxychloroquine? SYMPTOM Mild nausea, loss of appetite, or diarrhea Skin rash Blurry vision Headaches or dizziness Nervousness, restless, or sleeping difficulty Ringing in the ears (tinnitus) Eye problems (see below) FREQUENCY CALL DOCTOR Yes Yes Yes Do I need any monitoring while taking hydroxychloroquine? Although you do not need any regular blood tests while taking HCQ, your doctor may order periodic tests to follow the activity of your arthritis. However, you do need to have your eyes tested at least once a year while taking HCQ. Rarely, hydroxychloroquine (Plaquenil ) can cause problems in the back of the eye (retina). If this event were to occur, you might notice a problem with reading or seeing (words, letters, or parts of objects which would appear to be missing) or blurred vision. These problems seem to be related to the daily dose of medication. Fortunately, this is very. Early eye problems are not usually a serious problem and indicate sluggish muscles involved in focusing the lens of the eye. Damage to the retina almost never occurs until one has been on this medication for over 2 years. However, once damage occurs, it may be permanent. Therefore, appropriate monitoring of the eye by a medical specialist familiar with the side-effects of chloroquine and hydroxychloroquine is essential. The eye examination includes regular tests such as vision and eye pressure. It also includes tests which are not part of a regular eye check-up such as testing for colour vision and testing your visual fields. 22

23 Hydroxychloroquine Key Points 1 Taken once or twice daily 2 Yearly eye tests 3 Call MD if you get a rash key points LEFLUNOMIDE (LEF) Brand Name: Arava Supplied: 10 & 20 mg tablets What types of arthritis is leflunomide used for? Leflunomide (LEF) is a DMARD used to treat inflammatory types of arthritis like rheumatoid and psoriatic arthritis. What is the typical dose and when do I take it? LEF is taken as a tablet every day or every other day. The usual dose is 10 to 20 mg per day. Taking 20 mg every other day is very similar to taking 10 mg daily and is cheaper! How long will it take to work? Unfortunately, like many of the DMARDs, you won t feel the effects of LEF right away. Most people start noticing the effects about 6 to 8 weeks after they start to take it. What are the side effects of leflunomide? SYMPTOM Nausea and diarrhea Skin rash Thinning hair Increase in blood pressure Lung problems: difficulty breathing, dry cough, fever Liver problems Blood counts Infection FREQUENCY CALL DOCTOR Yes Have BP monitored by family doctor regularly Yes always Monitored by regular blood tests Monitored by regular blood tests Yes Call if you think you have an infection 23

24 Leflunomide Key Points 1 Take it once a day 2 Avoid alcohol 3 Regular blood tests 4 Don t get pregnant 5 Call MD if you develop a rash 6 Stop LEF if you develop shortness of breath, dry cough or fever key points Is there anybody who should not take leflunomide? Any woman who is pregnant or may become pregnant should not take LEF. LEF taken during pregnancy can cause birth defects in the unborn child and should be avoided at all cost. Any woman who is breastfeeding should also avoid LEF. People with active infections, liver, kidney, or blood diseases may not be able to use LEF and should discuss with their doctor. Is there anything I should avoid when I am taking leflunomide? Yes, avoid alcohol. LEF has the potential to affect the liver (ly), and so your alcohol use must be severely restricted. Talk to your doctor. Do I need any monitoring while taking leflunomide? You will need regular blood tests to monitor your liver and blood counts for side effects of LEF. How to help reduce side effects? Take LEF as prescribed by your doctor. Reducing the dose to 10 mg per day or taking 20 mg every other day may be helpful in reducing side effects. METHOTREXATE (MTX) Brand Name: APO-Methotrexate Supplied: 2.5 mg tablets, 50 mg/2ml vials for injection What types of arthritis is methotrexate used for? MTX is a DMARD used to treat inflammatory types of arthritis like rheumatoid and psoriatic arthritis. What is the typical dose and when do I take it? MTX is given either as tablets or injection; the choice will be up to you and your doctor. The most important thing to remember is that MTX is only taken once a week. Choose a 24

25 day that places the least demands on you, since some people feel unwell (tired, sick to the stomach, loss of appetite, or headache) for a day or two after they take the MTX. If you are taking the tablets, each tablet contains 2.5 mg of MTX with the most dose ranging from 3 to 10 tablets per week or 7.5 to 25 mg. If you are taking 6 or more tablets a week the dose can be split to take half in the morning and half at night (e.g. if you are taking 6 tablets a week you take 3 with breakfast and 3 with dinner). If you are taking the injection, methotrexate is supplied in 2 ml vials containing a total of 50 mg. The most dose with injections ranges from 0.3 ml to 1.0 ml per week or 7.5 to 25 mg. How long will it take to work? Unfortunately, like many of the DMARDs, you won t feel the effects of MTX right away. Most people start noticing the effects about 6 to 8 weeks after they start to take it. Is there anybody who should not take methotrexate? Any woman who is pregnant or may become pregnant should not take MTX. MTX taken during pregnancy can cause birth defects in the unborn child or even a miscarriage and should be avoided at all cost. Any woman who is breastfeeding should also avoid MTX. People with active infections, liver, kidney, or blood diseases may not be able to use MTX and should discuss with their doctor. Is there anything I should avoid when I am taking methotrexate? Yes, avoid alcohol. MTX has the potential to affect the liver (ly), and so your alcohol use must be restricted. Talk to your doctor. The antibiotic trimethoprim (proloprim) should not be used with MTX. Trimethoprim is often combined with sulfa antibiotics. If you need an antibiotic for bladder, ear, or chest infection make sure that any doctor who treats you is aware of this restriction. What are the side effects of methotrexate? SYMPTOM Feel unwell for hours Increased sun sensitivity Headaches Hair loss Mouth sores Lung problems: difficulty breathing, dry cough, fever Liver problems Blood counts Infection FREQUENCY CALL DOCTOR No wear a minimum SPF 15 sunscreen No unless very severe Yes reduced with folic acid Yes always Monitored by regular blood tests Monitored by regular blood tests Yes Call if you think you have an infection 25

26 Methotrexate Key Points 1 Take it only ONCE A WEEK 2 Avoid alcohol 3 Regular blood tests 4 Avoid sulfa antibiotics 5 Don t get pregnant 6 Stop MTX if you develop shortness of breath, dry cough or fever key points Do I need any monitoring while taking methotrexate? You will need regular blood tests to monitor your liver and blood counts for side effects of methotrexate. How to help reduce side effects? To reduce some of the side effects of methotrexate (such as nausea and mouth sores) your doctor might suggest a supplement called folic acid to be taken daily or a few times a week while you are on MTX. Taking the MTX before going to bed can sometimes help as you may sleep through any unpleasantness such as nausea. Finally, switching from tablets to injections can help to reduce nausea and feelings of general unwellness. SULFASALAZINE (SSZ) Brand Name: Salazopyrin Supplied: 500 mg tablets; 500 mg EC tablets What types of arthritis is sulfasalazine used for? SSZ is a DMARD used to treat inflammatory types of arthritis like rheumatoid and psoriatic arthritis. What is the typical dose and when do I take it? SSZ is taken as tablets usually given twice a day. Each tablet contains 500 mg of SSZ. The est dose is 2 tablets (1000 mg) twice a day; however, your doctor may increase the dose to 3 tablets twice a day. As SSZ can upset the stomach, it is important to start the medication gradually and build up as directed by your doctor. 26

27 How long will it take to work? Unfortunately, like many of the DMARDs, you won t feel the effects of SSZ right away. Most people start noticing the effects about 6 to 8 weeks after they start to take it. Is there anybody who should not take sulfasalazine? Anyone who has had a prior allergic reaction to medications containing sulfa should avoid sulfasalazine. Patients who have had an allergy to ASA (Aspirin) should also avoid sulfasalazine. Is there anything I should avoid when I am taking sulfasalazine? Although it is generally advisable to avoid all medications during pregnancy, SSZ has been used safely and successfully to treat arthritis during pregnancy. Most medications can be given safely with SSZ. What are the side effects of sulfasalazine? SYMPTOM Nausea, diarrhea, and abdominal pain Headaches or slight dizziness Rash Sensitivity to the sun Blood counts Liver problems Kidney problems Infertility FREQUENCY very very very CALL DOCTOR Yes No wear a minimum SPF 15 sunscreen Monitored by regular blood tests Monitored by regular blood tests Monitored by regular blood tests May temporarily reduce sperm counts in men Do I need any monitoring while taking sulfasalazine? You will need regular blood tests to monitor your blood counts for side effects of sufasalazine. How to help reduce side effects? To reduce some of the side effects of sulfasalazine your doctor might suggest you start with a low dose (one tablet once or twice a day) and increase the dose slowly (adding a tablet or two every week) until you reach the final dose. Taking sulfasalazine with food may also help. 27

28 Sulfasalazine Key Points 1 Take it twice a day 2 Regular blood tests 3 Call MD if you develop a rash key points CORTICOSTEROIDS WHAT ARE CORTICOSTEROIDS? Cortisone is a hormone produced naturally by the body s adrenal glands that regulates routine inflammation from minor injuries. Major traumas such as broken bones or surgery depend upon the adrenal gland to produce even more cortisone. But the adrenal gland could never produce enough cortisone to meet the challenge of inflammatory arthritis. In the 1950 s physicians found that giving extra cortisone to patients with rheumatoid arthritis dramatically improved their symptoms. From this discovery, corticosteroids, also known as steroids, were developed and are some of the oldest, most effective, and fastest-working medications for inflammatory arthritis. Steroids can be given by mouth (prednisone), injected into the joint, injected into a muscle, or through an intravenous drip. COMMONLY USED STEROIDS BRAND NAMES PRODUCT COMMON DOSE RANGE ROUTE Prednisone Prednisone Low Dose: 1-10 mg per day Mod Dose: mg per day High Dose: 20+ mg per day ORAL Solumedrol Methylprednisolone mg INTRAVENOUS (IV) Solumedrol Kenalog Aristospan Celestone Soluspan Methylprednisolone Triamcinolone Acetonide Triamcinolone Hexacetonide Betamethasone mg mg mg 1-12 mg INTRA-ARTICULAR (Joint Injection) Depomedrol Methylprednisolone mg INTRA-MUSCULAR (Muscle Injection) 28